my memorable case! an unanticipated cardiac arrest & unusual...

MY MEMORABLE CASE!

AN UNANTICIPATED CARDIAC ARREST

&UNUSUAL POST-RESUSCITATION

PSYCHO-BEHAVIOURAL PHENOMENA & NEAR DEATH EXPERIENCE (NDE)

IN A PATIENT WITH PREGNANACY INDUCED HYPERTENSION

(PIH) AND TWIN PREGNANCY POSTED FOR ELECTIVE

LOWER SEGMENT CAESARIAN SECTION (LSCS):

A CASE REPORT

DR. MRIDUL M. PANDITRAO

CONSULTANT

Department Of Anesthesiology&

Intensive Care

Public Hospital Authority’s RAND MEMORIAL HOSPITAL

Freeport, Grand BahamaCommonwealth of the Bahamas

FORMERLY:

PROFESSOR, HEAD,IN-CHARGE OF ICUDEAN OF FACULTY OF MEDICINEDEPTT. OF ANAESTHESIOLOGY & CRITICAL CAREPAD. Dr. D.Y.PATIL MEDICAL COLLEGEPIMPRI, PUNEINDIA

INTRODUCTION

PERI-PARTUM MORBIDITY & MORTALITY

VARIED AETIOLOGIES of CARDIAC ARREST

SUCCESSFUL RESUSCITATION?

AFTER THAT????

A CASE OF POST CARDIAC ARREST

RESUSCITATION (CPR) UNDERGOING

ELECTIVE LSCS FOR PIH AND TWINS!

INTERESTING, UNEXPLANABLE PHENOMENA

IN POST-OP PERIOD!

CASE REPORT

24 Yrs. Old primi-gravida near term

B.P. 160/122 mm Hg.

Twins

Anti-hypertensive /other Therapy

Development of S/S of impending Eclampsia

Planned Elective L.S.C.S.

ANAESTHETIC MANAGEMENT

Standard Balanced G.A.

At birth of both Babies : infusion of Pitocin

Obstetricians: Intramyometrial Injections

Carbiprost x 3 injections

Pitocin 10 I.U.

“SUDDEN CARDIAC ARREST!”

CPR Started

Revived successfully in 3.5 – 4 minutes

ANAESTHETIC MANAGEMENT(CONTD.)

Surgery was allowed to commence. B.P. on Higher range 150-160/100-110

mm Hg. At the end of surgery, patient was

making spontaneous respiratory efforts.

Reversal was given and patient was extubated when she was fully conscious and responding to verbal commands.

Patient was shifted to ICU after 30 min.

IN ICU IMMEDIATE POST-OPERATIVELY

Patient had no recollection of intra-operative events

Did not recognize her relatives.

Patient Was drowsy but awake

Anticerebral oedema therapy was given.

NEXT 24 HOURS– 1 WEEK

Patient became oriented gradually, but had amnesia

Vitals and physiological functions were normal

Had difficulty with speech initially which later

improved

Patient was discharged after 1 week

JUST BEFORE DISCHARGE

Recollection of immediate pre-operative period

Anterograde amnesia after that

Remembrance of “travelling through dark terrain

with a distant bright light at the end of it”

Seemed to have heard “She’s no more/ She is

dead!”

REVIEW AT 6 MONTHS

Till 3 months ‘unusual experiences’

In Mirror, seeing her own image !

“Out Of Body” experiences

Hearing again that “ She is No More!”

Establishment of normal relationship with

own newborns, spouse and other family members

DISCUSSION

The “Near Death Experiences” – NDES

Have been described in detail in literature*

Neither discussed amongst medical fraternity

nor taught in syllabi and curricula and left in

the realm of the ambiguity**.•Greyson B, Stevenson I. Phenomenology of Near death experience. Am J Psychiatry 1980; 137:1193 – 6.•Gabbard GO, Twemlove SW, Jones FC. Do ‘Near-death experiences’ occur only near death? J. Nerv Ment.dis. 1981; 169:374 – 7• Kircher PM. Love is the Link: A Hospice Doctor shares her experiences of Near Death & Dying, New York 1995, Larson Publications•Blackmore, SJ. Near-death experiences in India: They have tunnels too. Journal of Near-Death Studies 1993 11(4) ;205-11•Parnia S, Waller DG, Yeates R, Fenwick P. A qualitative and quantitative study of the incidence, features and etiology of near death experiences in cardiac arrest survivors. Resuscitation 2001;48:149 - 56

“NEAR DEATH EXPERIENCES” – NDES

Especially Post cardiac Arrest & return after CPR

Unexplainable phenomenon

Cultural variations

But commonly reported through out the world

Never given importance by Medical fraternity

• French CC. Near-death experiences in cardiac arrest survivors. Prog. Brain Res.2005;150:351 - 67 • James D. What emergency Department staff need to know about Near Death experiences. Topics in Emergency Medicine

2004; 26:29 - 34.

Peri partum morbidity and even mortality is again a well

documented phenomenon*

Especially where surgical intervention has been required

Morbidity and mortality might be due to various etio-

pathological processes involved

Treatment modalities logically may be varied with their

final outcome.

• Say L, Pattison R C, GulazogluA M: WHO systematic review of maternal morbidity and mortality, the prevalence of severe acute maternal morbidity (near miss), Reproductive Health,2004,1 (1), 3

• Minauskiene M, Nadasauskiene R, Padaiga Z, Makari S: Systematic review on the incidence and prevalence of severe maternal morbidity; Medicina (Kaunas) 2004, 40 (4): 299-

Exact cause of the Catastrophe?

Cause of cardiac arrest is still a dilemma

“Delivery of babies?” or Intra-myometrial

injections of Carbiprost / Oxytocin

Post-CPR psychological Phenomena?

“O-O-B” experiences, “Dark Tunnel” have been

reported.

Carboprost tromethamine (Hemabate)®,

Methylated analogue of Prostaglandin F2 α (PGF2 α)

In clinical practice for fairly sometime

Many obstetrician use it*

to stimulate myometrial contractility,

increase the tone,

decrease the bleeding and reduce the incidence of PPH.

Routinely given by many Obstetricians intra-myometrially

• Brancazio LR, Stizel RE Uterine Simulates & Relaxants. In: Craig CR., Stitzel RE, editors. Modern Pharmacology with Clinical Applications. 6 th ed, Philadelphia: Lippincott Williams & Wilkins; 2003, p. 719-721

• Singh N, Singh U. Methylergometrine and carboprost tromethamine prophylaxis for post partum hemorrhage; J Obstet Gynecol of India 2005 ,55: 325-8

Oxytocin, although nowadays rare.

Carboprost, Misoprostol and other

uterine stimulants causing cardiac

arrest has been documented*.

• Adverse event in female receiving Hemabate (Carboprost). Reported by a physician from United States on 2007-03-09. Patient: female ...

www.druglib.com/adverse-reactions_side-effects/hemabate/seriousness_serious/

Successful revival of the patient suggests

Whatever was the cause of the event, was acute, transient

and not related to any organic lesion.

Further confirmed by the fact that she did not require any

support or any further sustained pharmacological intervention

The experiences that our patient had can be included under

the realm of NDEs, as per the Greyson’s NDE Scale (of more

than 7 )

• French CC. Near-death experiences in cardiac arrest survivors. Prog. Brain Res.2005;150:351 - 67 • James D. What emergency Department staff need to know about Near Death experiences. Topics in Emergency Medicine 2004; 26:29 - 34.

Various psychological phenomena in post-CPR

period

But our patient’s few more peculiar psycho-

behavioural experiences are not explainable to us.

Discussion with psychiatrists has not been very

conclusive.

Till date, this has been an enigma to us.

CONCLUSION

PIH Patient for elective LSCS, under GA

Suffered C-P Arrest,

Following delivery of babies and

Intra-myometrial Injections of a prostaglandin and

Oxytocin.

Post CPR ‘peculiar’ psycho-behavioral phenomena, which were

self-limiting.

Can be cofirmed as NDEs

Patient is now living “peaceful” life.

CONCLSION

Complicated Obstetrics can be very challenging and

put us through unusual situations

Intra-myometrial use of uterine stimulants can

be very risky and should be avoided as far as

possible

Making all healthcare givers, well acquainted

with the knowledge of “Out of Body”/ NDEs in

post CPR period must be part of our curriculum

In addition to already reported behavioral changes,

new experiences could be added to the existing list.

It is our fervent wish and earnest effort to make all aware that:

Post CPR NDEs might be

difficult to explain but are a

real phenomena

Clinicians must be, less

sceptic & more considerate

about their existence !!

ALREADY PUBLISHED AS A CASE REPORT:

Indian J Anaesth. 2010 Sep-Oct; 54(5): 467–469. doi:  10.4103/0019-5049.71035PMCID: PMC2991660An unanticipated cardiac arrest and unusual

post-resuscitation psycho-behavioural phenomena/near death experience in a patient with pregnancy induced hypertension and twin pregnancy undergoing elective lower segment caesarean section

Mridul M Panditrao, Chanchal Singh,1 and Minnu M Panditrao

Thank You!